6 Who should be referred for endoscopy? Those in whom upper GI cancer is a real possibility If endoscopy, get maximum information Avoid acid suppression if possible If need acid suppression prefer H-2ra to PPI

9 Refer if dyspepsia in 55+ year old and Alarm symptoms/signs (2 week referral) Unexplained and persistent recent-onset dyspepsia without alarm symptoms Unexplained means no cause known (and implies no recent endoscopy) Persistent implies present for a length of time (NICE suggest 4-6 weeks) Recent-onset implies new not a recurrent episode

10 What to do when refer for endoscopy Get maximum information Avoid acid suppression if possible at least for two weeks and preferably for 4 weeks If need acid suppression prefer H-2ra to PPI

17 New approach to community dyspepsia (SIGN and NICE) Manage symptoms rather than make a diagnosis (i.e. treat dyspepsia, not its cause) Avoid endoscopy for dyspepsia ALONE if <55 years (do if alarm symptoms or >55) Empower patients to manage their own symptoms

19 Management of simple dyspepsia in those aged < 55 years Then what next if persistent?

20 NICE guideline summary Refer if alarm symptoms at any stage Test and treat (Test for H. pylori and treat positives) THEN, IF STILL SYMPTOMATIC PPI for one month or vice versa THEN Manage recurrent symptoms as functional dyspepsia

21 How to test? Urea breath test most accurate but most costly Stool antigen test Acceptability? Serology Near patient tests are inaccurate Best serum-based ELISAs are accurate Advantage of being less affected by PPIs and concurrent antibiotics

24 Third line treatment Referral to John Atherton Usually endoscopy + H. pylori culture/abio sens Treat according to sensitivities

25 Retesting after treatment Usually unnecessary if treatment for uninvestigated dyspepsia If needed, do urea breath test or stool antigen test NOT SEROLOGY Avoid antibiotics and bismuth for 4 weeks and PPIs for 2-4 weeks before test

26 NICE guideline summary Refer if alarm symptoms at any stage Test and treat (Test for H. pylori and treat positives) THEN, IF STILL SYMPTOMATIC PPI for one month or vice versa THEN Manage recurrent symptoms as functional dyspepsia

31 Should we treat H. pylori in patients on long term PPIs? H. pylori treatment slows development of atrophy and intestinal metaplasia No evidence that H. pylori treatment prevents gastric cancer in this group. PPIs are more effective in some people if H. pylori positive Treatment can have side effects Risk-benefit too unclear to recommend treatment in all

33 Simple dyspepsia in < 55 year old Two options 1. Test and treat approach Equivalent or better for simple dyspepsia in the community Less costly Most clearcut benefit where H. pylori prevalence high

34 Simple dyspepsia in < 55 year old Two options 2. PPI course approach May be best where prevalence of H. pylori is low This will include younger patients

35 Simple dyspepsia in < 55 year old Try both options If continuing symptoms reassure Manage as functional dyspepsia Re-assess on yearly basis Referral always an option if inadequate response to therapy or if you are worried

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